LVAs in a Pedicled SIEA Flap for the Treatment of Recurrent Lymphocele of the Groin Using Superficial Veins of the Flap for Lymphovenous Anastomosis: A Case Report and Literature Review.

Persistent lymphocele of the groin is a complication of groin surgery that can severely impact the quality of life. The restoration of the interrupted lymphatic pathway is considered by many authors the ideal treatment to prevent a recurrence. However, multiple aspiration procedures and surgical revisions can compromise the availability of local veins needed for a lymphovenular bypass surgery. In addition, surgical debridement of a long-standing lymphocele can generate extensive dead space and contour deformity. A flap delivering additional venules for trans-flap lymphovenular anastomoses (LVAs) can overcome both problems by providing soft tissue and competent veins harvested outside the zone of injury. A successful case of severe groin lymphocele treated with trans-flap LVAs from an abdominal-based flap is presented. The patient was referred to us for a recurrent lymphocele developed in the right groin after lipoma excision that persisted despite multiple surgical attempts. After the identification of patent and draining inguinal lymphatic vessels, a pinch test was used to design a mini-abdominoplasty superficial inferior epigastric artery flap. The superficial veins of the cranial incision were identified and anastomosed to the lymphatic vessels after the pedicled flap harvested and insetted in the groin. The early restoration of lymphatic drainage and the optimal aesthetic outcome supports the combined approach offered by trans-flap LVAs as a valuable therapeutic option for severe and persistent lymphocele.

SCIP flap in head and neck reconstruction after oncologic ablative surgery: a systematic review.

BACKGROUND: In the surgical treatment of head and neck locally advanced malignancies, microvascular free flaps represent the most valuable solution to reconstruct the tissue defect after resection of the primary neoplasm. In particular, microvascular free flaps allow to restore the functional and aesthetical features of the head and neck compartments. The superficial circumflex iliac perforator (SCIP) flap represents, as an evolution of the groin flap, a valid alternative to the radial fasciocutaneous free (RFFF) flap or the anterolateral thigh (ALT) flap. METHODS: This systematic review adhered to the recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine ( www.pubmed.org ) and Scopus database ( www.scopus.com ). Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes, and complications. RESULTS: A total of 25 articles were selected and reviewed among the 39 identified through the search string. Six out of the selected 25 articles were case reports, while the remaining 19 articles were retrospective case series. The whole study population was represented by 174 oncologic patients undergoing ablation of a head and neck tumor and reconstruction with a SCIP flap. The site of reconstruction was the oral cavity in 125 (71.0%) patients, being the tongue the most common subsite in 73 (41.5%) patients, the pharynx in 10 (5.7%) cases, the larynx in 3 (1.7%) and head and neck skin in 36 (20.4%) patients. Only two cases of total flap loss were reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 11 patients (6.32%). Primary closure of the donor site was achieved in the whole study population, according to the available data. CONCLUSIONS: In head and neck postoncological reconstruction, despite the caliber and the length of the pedicle, SCIP flap offers a pliable and thin skin paddle, allowing single-stage resurfacing, medium to large skin paddle, possibility of composite-fashion harvest and a well-concealed donor site.

Cause specific mortality in an Italian pool of asbestos workers cohorts.

BACKGROUND: Asbestos is a known human carcinogen and is causally associated with malignant mesothelioma, lung, larynx and ovarian cancers. METHODS: Cancer risk was studied among a pool of formerly asbestos-exposed workers in Italy. Fifty-two Italian asbestos cohorts (asbestos-cement, rolling-stock, shipbuilding, and other) were pooled and their mortality follow-up was updated to 2018. Standardized mortality ratios (SMRs) were computed for major causes of death considering duration of exposure and time since first exposure (TSFE), using reference rates by region, age and calendar period. RESULTS: The study included 63,502 subjects (57,156 men and 6346 women): 40% who were alive, 58% who died (cause known for 92%), and 2% lost to follow-up. Mortality was increased for all causes (SMR: men = 1.04, 95% confidence interval [CI] 1.03-1.05; women = 1.15, 95% CI 1.11-1.18), all malignancies (SMR: men = 1.21, 95% CI 1.18-1.23; women = 1.29, 95% CI 1.22-1.37), pleural and peritoneal malignancies (men: SMR = 10.46, 95% CI 9.86-11.09 and 4.29, 95% CI 3.66-5.00; women: SMR = 27.13, 95% CI 23.29-31.42 and 7.51, 95% CI 5.52-9.98), lung (SMR: men = 1.28, 95% CI 1.24-1.32; women = 1.26, 95% CI 1.02-1.53), and ovarian cancer (SMR = 1.42, 95% CI 1.08-1.84). Pleural cancer mortality increased during the first 40 years of TSFE (latency), reaching a plateau thereafter. CONCLUSIONS: Analyses by time-dependent variables showed that the risk for pleural neoplasms increased with latency and no longer increases at long TSFE, consistent with with asbestos clearance from the lungs. Peritoneal neoplasm risk increased over all observation time.

Tranexamic Acid Use in Breast Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: The perioperative use of tranexamic acid (TXA) has become popular among plastic surgeons for a variety of surgical procedures. The aim of this study was to perform a systematic review and meta-analysis on the results reported in the literature regarding the effect of perioperative systemic TXA administration in breast surgery. METHODS: The PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio with corresponding 95% confidence interval. RESULTS: A total of five studies encompassing 1139 patients undergoing mastectomy with or without immediate implant or free flap-based breast reconstruction or breast-conserving surgery with or without axillary lymph node dissection were included. Perioperative intravenous administration of TXA significantly reduced the risk for hematoma (7.3% versus 12.9%; OR, 0.43; 95% CI, 0.23 to 0.81) and seroma formation (11.5% versus 19.9%; OR, 0.57; 95% CI, 0.35 to 0.92) in comparison to the control group. In the studies measuring the postoperative drainage amount, the mean difference was 132 mL (95% CI, 220 to 44 mL). No thromboembolic event occurred in either group. The weighted surgical-site infection rate was higher in the control group (3.1% versus 1.5%). However, these data were too sparse to perform comparative meta-analysis. CONCLUSION: Evidence of this study suggests that perioperative administration of TXA significantly reduces the risk for postoperative hematoma and seroma formation in breast surgery, whereas the risk for thromboembolic events and postoperative infection is not increased.

Our experience with the anterior interosseous artery fasciocutaneous flap for local and distant soft tissue reconstructions.

BACKGROUND: Martin and his colleagues in 1989 described for the first time a fasciocutaneous flap based on a posterior branch of the anterior interosseous artery (AIA). Despite its promising characteristics, this flap never achieved popularity and the literature about it is limited. The aim of the present study is to share our experience with the AIA flap both as a local and free flap in reconstructing defects of various body regions. PATIENTS AND METHODS: A retrospective review of 26 consecutive patients operated between January2001 and August 2020 was conducted. Seventeen male and nine female patients, mean age 52 years, underwent reconstruction of local and distant soft tissue defects using the AIA flap. Fourteen flaps were raised as free flap and 12 as local flaps for a total of 26 flaps. The locations of the defects included the face, the lower limb, the hand dorsum, and fingers. RESULTS: Twenty-four out of 26 flaps survived completely, and two pedicled flaps presented partial necrosis, with one requiring a new free flap procedure. One free anterior interosseous flap required revision of the venous anastomosis. Two donor site dehiscence were observed, and they both healed by secondary intention healing. Follow-ups were conducted for a mean of 18 months. All patients showed good contour restoration of the affected body part. CONCLUSIONS: The AIA flap, either free or pedicled, represents a reliable tool to perform "like-with-like" reconstructions of hand defects. In some occasions, it is well suited for shallow defects in other body parts.

Candida Albicans Osteomyelitis after Chest Wall Blunt Trauma: A Case Report.

Fungal osteomyelitis is a rare disease that can occur in immunocompromised patients. We report a case of a patient with a primary rib osteomyelitis after a blunt trauma of the chest wall. Aggressive surgical debridement along with antifungal therapy was the cornerstone of the disease management in this patient.

Sequential propeller flaps in the treatment of post-traumatic soft tissue defects of the lower limb - a case series.

INTRODUCTION: Propeller flaps have gained great popularity among reconstructive surgeons; however, the inability to directly close the donor site of large propeller flaps constitutes a well-known limitation of this technique. Skin grafting of the donor area is not always feasible nor desirable. To address large propeller flaps secondary defects, we investigated the use of a second propeller flap harvested from a nearby region of relative skin redundancy to assist the donor site closure generated by the first. Since the donor defect of the second flap is closed by direct suture, the aim of this "sequential" propeller flaps technique is to achieve complete, like-with-like, soft tissue restoration while avoiding skin grafting. METHODS: From April 2018 to September 2019, eight patients presenting post-traumatic soft tissue defects were planned to be reconstructed by means of the sequential propeller flaps technique, for a total of 16 propeller flaps. The locations of the defects included the distal leg in four cases, the heel in two cases, the proximal lateral thigh in one case and proximal posterior thigh in the remaining one. All the flaps but one were harvested as a perforator-based propeller type and rotated by different degrees around the skeletonized perforator. In one patient, due to an intraoperative complication following the first flap harvest, the harvest of the second flap was abandoned. RESULTS: In all but one patient, a complete, tension free primary closure of all wounds was achieved without complications, the functional recovery as well the esthetic outcome were excellent. One patient showed intraoperative signs of vascular insufficiency involving 15% of the first flap. The plan of harvesting the second flap was intraoperatively abandoned and the definitive wound closure with a free muscle gracilis was carried out the following week. CONCLUSION: In some selected cases, the use of multiple propeller flaps performed in sequence allows the surgeon to obtain complete, like-with-like wound closure with vascularized tissue avoiding a free tissue transfer procedure, however, it requires a vast experience with propeller flaps and meticulous preoperative planning.

Combined lymphovenous anastomosis and deep inferior epigastric perforator flap with lymphatic tissue preservation for defect reconstruction and lymphedema-lymphocele prevention after medial thigh sarcoma resection: A case report.

Soft tissue sarcomas are a rare group of malignant tumors that often require an extensive surgical resection to be safely treated. When they are localized in the upper medial thigh, this treatment inevitably leads to large defects frequently causing a series of early and late postoperative complications. Among these, lymphocele and lymphedema are rather common and should try to be avoided. Many solutions with a demonstrated efficacy have been described for this purpose after groin dissection procedure, ranging from lymphovenous anastomosis to pedicled or free flaps. Anyway, there is much less information regarding the medial thigh. Here we present a case of resected sarcoma involving the adductors compartment reconstructed using a pedicled deep inferior epigastric (DIEP) flap with lymphatic tissue transfer, combined with preventive lymphovenous anastomosis (LVA) performed at the superior-edge-of-the-knee incision (SEKI) point. A 58-year-old patient presented a 10 cm × 12 cm soft tissue defect after margin free sarcoma removal. To fill this defect, we harvest a 24 × 9 cm pedicled DIEP flap conserving its lymphatic vessels running from the upper margin to the right groin lymphnodes. Then we rotated it maintaining the lymphnodes in their original site and moved it through an inguinal tunnel in the area of the defect. The distal part was de-epithelized and folded down to cover the deeper region. The postoperative course was uneventful and at the 6 months follow up the patient showed a good outcome with no swelling and no signs of tumor relapse. This result therefore may suggest that this kind of combined treatment might be an effective technique to prevent all those complications linked to the impairment of lymphatic system drainage in the proximal medial thigh.

Propeller flap donor site closure by means of another propeller flap: A case report and literature review.

Despite some ongoing criticisms, propeller flaps are still gaining popularity among plastic surgeons. The need of skin grafting of the donor site is one of those limitations that sometime affect the beauty and the efficacy of this reconstructive technique. Similar to a classic bi-lobed skin flap in which the second lobe of the same flap is mobilized to cover the donor site defect of the first lobe, a second, discrete propeller flap can be harvested adjacent to the first, in order to close the first donor site defect, thus avoiding the need for a skin graft. We applied this concept of "sequential" propeller flaps to cover a 4.5 × 4 cm full thickness soft tissue defect at the level of the heel in a 54-year-old patient who underwent melanoma excision and sentinel node biopsy.The first and second propeller flaps of 10 × 4.5 cm respectively were rotated on a distal and on a more proximal perforator of the posterior tibial artery (PTA) respectively, obtaining a tension free closure along the entire wound. The post-operative course was uneventful and the patient returned to full normal activities after 4 weeks. Follow up at 6 months showed a stable reconstruction with no functional deficit. This option, that relies on two separate perforator propeller flaps performed in sequence to obtain complete wound closure, may be kept in mind when dealing with soft tissue defects eligible for propeller flap reconstruction, as long as sizeable perforators in a favorable position are available. Moreover, a brief literature review on propeller flap use in flap donor site closure is also provided.

Groin defect reconstruction with perforator flaps: Considerations after a retrospective single-center analysis of 54 consecutive cases.

INTRODUCTION: Groin defects with exposed complex structures are challenging to treat. Perforator flaps provide a contemporary alternative to established muscle flaps to cover all varieties of groin defects, with minimum donor site morbidity, less postoperative pain, and faster rehabilitation. In this retrospective single-center analysis, we aimed to show that pedicled perforator flaps are a valid option for groin defect reconstruction. We present three different pedicled perforator flaps and discuss the flap selection process and their distinct advantages and disadvantages. METHODS: A series of 54 consecutive cases of patients with groin defects were allocated into three different treatment groups. Reconstruction was performed utilizing the anterolateral thigh (ALT) flap, the pedicled posteromedial thigh (PMT) perforator flap, and the vertical deep inferior epigastric artery perforator (vDIEP) flap. RESULTS: All 54 flaps survived. Early complications included one hematoma (vDIEP) and two infections (ALT and PMT). Delayed complications occurred in three recipient-site seromas (ALT, PMT, and vDIEP), one donor-site seroma (vDIEP), and one flap dehiscence (ALT). All flaps provided stable coverage during 3-12 months of follow-up. CONCLUSION: We propose pedicled perforator flaps to be a safe and reliable option for groin defect reconstruction. The pedicled PMT flap should be the first choice if the profunda femoris artery and its perforators are available. The ALT flap can be applied as a second choice, especially if complex groin defect with exposed vascular prosthesis reconstruction is needed because of its versatile expansion options, for example, as a chimeric flap using a portion of the vastus lateralis muscle. In cases where the profunda femoris artery is not available, the vDIEP flap should be the preferred method.

The use of chimeric musculocutaneous posterior interosseous artery flaps for treatment of osteomyelitis and soft tissue defect in hand.

INTRODUCTION: There is growing evidence of the superior ability of muscular tissue to clear bacterial bone infection. Unfortunately, in the hand, there are almost no small local muscular flaps, and muscular transfers to the hand are mainly microsurgical free transfers. In this report, we present the results of the use of a chimeric posterior interosseous flap including part(s) of the forearm muscles to treat osteomyelitis and soft tissue defect of hand from a series of patients. PATIENTS AND METHODS: Four male patients with an average age of 32 years (range 20-46 years), were affected by acute osteomyelitis in hand. Previous fracture fixation with percutaneous K-wires was the cause of bone infection in three case. In one case, the osteomyelitis was a consequence of an open fracture. The bones affected were four metacarpals and one proximal phalanx, all with a minimal cortical defect (from the K-wire) obscuring a larger medullary infection, which required extensive bone and overlying soft tissue debridement, leaving a soft tissue defect to be reconstructed of size ranging from 2 x 4 cm to 5 x 7 cm. The soft tissue defects were due to concomitant superficial infection and consequent debridement. All patients were treated with bone debridement and a chimeric posterior interosseous flap, which included part of the extensor digiti minimi and/or extensor carpi ulnaris to fill the intramedullary canal of the bones. No fixation of bone was necessary. RESULTS: The skin paddle of the flaps ranged from 2 x 5 cm to 5 x 6 cm, replicating the defect area, plus a teardrop tail of skin circa 1.5 cm wide and as long as the pedicle of the flap. The muscular components of the flaps used to fill the intramedullary canals ranged from 1 x 1 x 1.5 cm to 1.5 x 1.5 x 4 cm. All flaps survived and osteomyelitis resolved in all cases without major complications. At the final follow-up at 16 months (range 12-26 months), assessment of the hands using TAM, Power Grip and Key Pinch Strength measurements and, where appropriate, Kapandji scores, demonstrated satisfactory hand function. CONCLUSION: The chimeric posterior interosseous flap including part of the muscles of the forearm may be a robust solution for augmenting the flap bulk and may be used in cases of severe osteomyelitis of the hand.